Introduction

Disparities and Rural Health

Access to excellent health care is notevenly distributed in the United States.Rural residents often face barriers tohigh quality care. Compared with theirurban counterparts, residents of ruralareas:

Report fair or poor health.

More often have chronic conditionssuch as diabetes.

Die from heart disease.1,2

However, despite greater need forhealth care, rural residents have fewervisits to health care providers and areless likely to receive recommendedpreventive services.3 Rural minoritiesappear to be particularly disadvantaged,and differences are observed in cancerscreening and management ofcardiovascular disease and diabetes.4,5

Several factors may contribute to ruralresidents poorer health and health care.For example:

Although 20 percent of Americanslive in rural areas only 9 percent ofthe Nation's physicians practicethere.6

Rural residents face longer distancesto reach health care delivery sites.

Each year beginning in 2003, theAgency for Healthcare Research andQuality (AHRQ) produces theNational Healthcare Disparities Report.Mandated by Congress, this report:

Examines the status of racial andsocioeconomic health caredisparities in America.

Tracks progress towards theelimination of disparities in qualityand access, both for the Nation as awhole and for AHRQ'scongressionally designated prioritypopulations.i

The mission of AHRQ is to improve the quality,safety, efficiency, and effectiveness of healthcare by:

Using evidence to improve health care.

Improving health care outcomes throughresearch.

Transforming research into practice.

Health Care Disparitiesin Rural Areas

F A C T S H E E T

Advancing Excellence in Health Care www.ahrq.govAgency for Healthcare Research and Quality

Selected Findings From the 2004 NationalHealthcare Disparities Report

i In addition to rural residents, AHRQs Priority populations include racial and ethnic minorities,low income groups, elderly, women, children, and individuals with special health care needs.

2

Includes information aboutdisparities in rural populationsacross metropolitan, micropolitan,and non-core based statistical areas.

Purpose of This Fact Sheet

This Fact Sheet presents findingsrelated to rural health care from the2004 disparities report by describing,for selected measures:

Quality of care for diabetes andheart attack (acute myocardialinfarction).

Access to health insurance coverage.

Utilization of dental services.

Quality of Care

The disparities report examines qualityof care in nine clinical condition or caresetting areas. Findings in two of theseareas, diabetes and heart disease, arebriefly presented below.

Diabetes

Effective outpatient care for diabetesreduces admissions for uncontrolleddiabetes. Although not all uncontrolleddiabetes admissions can be avoided,rates in populations tend to vary withaccess to outpatient services.

In 2001, rates of admissions foruncontrolled diabetes were higheramong residents of micropolitanand non-core based statistical areasthan among residents ofmetropolitan statistical areas (Figure1), suggesting problems withoutpatient care.

Admission rates for uncontrolleddiabetes were higher among blacksthan among whites in all geographicareas and highest for blacks in non-core based statistical areas176.3admissions per 100,000 population.

0

50

100

150

200White

Black

Metropolitan Non-CoreMicropolitan

Rat

e

13.8

76.7

24.1

123.3

35.0

176.3

Figure 1. Adult admissions for uncontrolled diabetes without complications per100,000 population, by race

Source: Healthcare Cost and Utilization Project, State Inpatient Databases disparities analysis file,2001.Key: Metropolitan = 50,000 or more inhabitants; micropolitan = 10,000 to 50,000 inhabitants; non-core = not metropolitan or micropolitan.

Heart Attack

Inpatient death rates may in part reflectaccess to high quality hospital care.Although many inpatient deaths amongpatients hospitalized for myocardialinfarction cannot be prevented, rates inpopulations may vary with quality ofcare.

In 2001, inpatient deaths amongadults admitted for acute myocardialinfarction were higher amongresidents of micropolitan and non-core based statistical areas thanamong residents of metropolitanstatistical areas (Figure 2), suggestingproblems with quality of hospitalcare.

Inpatient death rates were highestamong Hispanics in non-core basedstatistical areas155.6 deaths per1,000 admissions.

Access to Health Insurance

Health insurance facilitates initial entryinto the health care system. Theuninsured report more problems gettingcare7 and are sicker when hospitalized.8

In 2002, 15.2 percent of Americanswere uninsured.9

In 2001, similar percentages ofpeople under 65 in largemetropolitan, small metropolitan,micropolitan, and non-core basedadjacent statistical areas reported aperiod of uninsurance in the pastyear (Figure 3).

The proportion of people under 65with any period of uninsurance inthe past year was higher amongHispanics compared with non-Hispanic whites in all four statisticalareas.

The percent of those uninsuredsometime in the past year washighest among Hispanics in non-core based statistical areas adjacentto metropolitan or micropolitanareas59.7 percent. 3

0

50

100

150

200White

Metropolitan Non-Core

Hispanic

Micropolitan

Rat

e

96.4106.7

99.197.8108.3

155.6

Figure 2. Deaths per 1,000 adult admissions for acute myocardial infarction, byrace/ethnicity

Source: Healthcare Cost and Utilization Project, State Inpatient Databases disparities analysis file,2001.Key: Metropolitan = 50,000 or more inhabitants; micropolitan = 10,000 to 50,000 inhabitants; non-core = not metropolitan or micropolitan.

0

20

40

60

Per

cent

Non-Hispanic White

Hispanic

Large M

etropoli

tan

Small M

etropoli

tan

Microp

olitan

Non-Co

re Adjac

ent

19.7

46.7

22.8

41.7

21.8

50.8

24.7

59.7

Figure 3. People under age 65 with any period of uninsurance in past year, byethnicity

Source: Medical Expenditure Panel Survey, 2001Key: Large metropolitan = 1 million or more inhabitants; small metropolitan = < 1 million inhabitants;micropolitan = 10,000 to 50,000 inhabitants; non-core adjacent = not metropolitan or micropolitanbut adjacent to metropolitan or micropolitan area.

www.ahrq.gov

AHRQ Pub No. 05-P022May 2005

Dental Care Utilization

Routine dental care helps maintainhealthy teeth. Lower utilization ofdental services may suggest lack ofaccess to care.

In 2001, residents of non-core basedstatistical areas not adjacent tometropolitan or micropolitan areaswere less likely to report a dentalvisit in the past year than residentsof large metropolitan statistical areas(Figure 4).

The proportion of people withdental visits in the past year waslower among blacks compared withwhites in all four statistical areas.

For More Information

Further analysis and data from theNational Healthcare Disparities Report

as well as its companion NationalHealthcare Quality Report are availableat: www.qualitytools.ahrq.gov.

Additional information on AHRQ andits programs and activities can be foundat: www.ahrq.gov.

References

1. Muskie School of Public Service andKaiser Commission on Medicaidand the Uninsured. Healthinsurance coverage in rural America.Washington, DC: Kaiser FamilyFoundation; 2003.

2. Rural primary care. AmericanCollege of Physicians. Ann InternMed. 1995 Mar 1;122(5):380-90.

3. Larson SL, Fleishman JA. Rural-urban differences in usual source ofcare and ambulatory service use:analyses of national data using

Urban Influence Codes. Med Care.2003 Jul;41(7 Suppl):III65-III74.

4. Hartley DL, Quam L, Lurie N.Urban and rural differences inhealth insurance and access to care. JRural Health. 1994Spring;10(2):98-108.

5. Slifkin RT, Goldsmith LJ, RickettsTC. Race and place: urban-ruraldifferences in health for racial andethnic minorities. Chapel Hill, NC:University of North Carolina atChapel Hill; 2000.

6. van Dis J. MSJAMA. Where welive: health care in rural vs urbanAmerica. JAMA. 2002 Jan2;287(1):108.

7. Freeman HE, Aiken LH, BlendonRJ, Corey CR. Uninsured working-age adults: characteristics andconsequences. Health Serv Res.1990 Feb;24(6):811-23.

8. Hadley J, Steinberg EP, Feder J.Comparison of uninsured andprivately insured hospital patients.Condition on admission, resourceuse, and outcome. JAMA. 1991 Jan16;265(3):374-9.

9. Mills RJ, Bhandari S. Healthinsurance coverage in the UnitedStates: 2002. Current PopulationReports P60-223. Washington, DC:U.S. Census Bureau; 2003.

4

0

20

40

60

Per

cent

White

Black

Large M

etropoli

tan

Small M

etropoli

tan

Microp

olitan

Non-Co

re Adjac

ent

46.0 46.6

28.727.0

42.1

21.7

38.5

16.7

Figure 4. People with a dental visit in past year by race

Source: Medical Expenditure Panel Survey, 2001.Key: Large metropolitan = 1 million or more inhabitants; small metropolitan = < 1 million inhabitants;micropolitan = 10,000 to 50,000 inhabitants; non-core adjacent = not metropolitan or micropolitan butadjacent to metropolitan or micropolitan area.